20120879 Ver 1_401 Application_20120912

20120879
\0 of WAT 9pL Office Use Only:
Corps action ID no.
1
DWQ project no.
Form Version 1.4 January 2009
Pre - Construction Notification (PCN) Form
A. Applicant Information
1. Processing
1 a. Type(s) of approval sought from the Corps:
❑ Section 404 Permit ❑ Section 10 Permit
1 b. Specify Nationwide Permit (NWP) number: or General Permit (GP) number:
1c. Has the NWP or GP number been verified by the Corps?
❑ Yes ❑ No
1 d. Type(s) of approval sought from the DWQ (check all that apply):
❑ 401 Water Quality Certification — Regular ❑ N - 04 Jurisdictional General Permit
❑ 401 Water Quality Certification — Express Riparian Buffer Authorization;
1 e. Is this notification solely for the record
because written approval is not required?
For the record only for DWQ
401 Certification:
❑ Yes ❑ No
For the record only for Corps Permit:
❑ Yes ❑ No
1f. Is payment into a mitigation bank or in -lieu fee program proposed for;_
mitigation of impacts? If so, attach the acceptance_ letter from mitigation bank;
or in -lieu fee program.' - --
❑ ;Yesl o)
C Is the project located in any of NCs twenty coastal counties. If yes, answer
❑'Yesi �,Noj
below.T - - - --
1h Is the project located within a NC DCM�Are_a_of Enviro_nmental_Con_cem (AEC)J
❑�Yesf o;
2. Pro'ect Information;
2a_ Name of project,
k„ & k 6 '7 f e 5d&,
C-- - - - --- — --- .--- - - - --- -
�2c. _Nearest municipality / towns;
C2d. Subdivision name j
2e. NCDOT only, T.I.P. or state project no:
(3} Ldwn: SEP 2 4
(3a_ Name(s) on ^Recorded Deed
D a J 2 p d- Lo t a p v yi a
19 L41 3 PQ e
(36._Deed Book and Page No;,
3c. Responsible Party (for LLC if)
iapplicable):I
+3d _Street idd ress:,+
4e. City, state, zip:)
(3f. Tele phone ,no_1
R I '7 q
- g -70 / 2 2 3 qlq W Y 7 •9' S" 5
Lag_ -Fax no_:}
- --
'3h. Email address:
L3h. - mail address:',
Lo L AS L 1 f
Page 1 of 10
PCN Form — Version 1.4 January 2009

4.) Applicant Information (if different from owner);
4a. rA pip -1 -i c-_ ant _
a n t- —is:')
(jc._ Business name)
((if applicable):)
(4d. Street address
4e. state, zip:;
,4f. -Telephone no.
(4grFax no.
C4-h-.—E--m-- ai-ifa-dkire----'
5a.
L5b. Business name
;,(if applicable):
Street address:)
;5d. qlx' state, zip:�
,5e. Telephone no.,
Cgs -Email i C;�ddr
Page 2 of 10

�B. Project Information and Prior Project History
Property Identificatio
Fla. Property identification no. (tax PIN or parcel ID):
0-7 q (o 1-2, '7 1-1-7 000
(1 b Site coordinates (in decimal degrees):
I Latitude:; ] 5 , t 7 0 Z Longitudes '] �' � ? $ ?j
1 c Property size: ,
acres
(21 `Surface waters
i !. Name of nearest body of water to proposed projects
(Lm i w
L2b. Water Quality Classification of nearest receiving water:`r
cq7 3 Ll
�2c. River basin:;
Project Description?
�3a. Describe the existing conditions o_ n_th_ the site and the general land use in the vicinity of the project at the time of this)
i
;aPPlicatiorr;i Tk2re I-j a 51 KJ 1 e -Ptq�w r 1 kI P e-5 cQ�, ,�Q.I (� c114 S c -� -- '" "(S
VrOpTtfy
3b. List the total estimated acreage of all existing wetlands on the property:
3c. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property.) AJ I}
4d. Explain the purpose of the proposed project:} Tear 6( c4 A ,% a 0-t d� � � � g � "S e-
A +- B
.e�K 4_ c P h Of � aw S ,e. Y 9 cC. � a 1 �Vj >rLQ.GC�
_Describe the overall project in detail,--including the type of equipment to be used, f 4-3
�r rrr+ C4 2o�r2
4. Jurisdictional Determinations
A4 . Have jurisdictional wetland or stream determinations by they
-
(,Corps or State been requested or obtained for this roe /)
p q I? p m! 1
- - -
_;Yes, ❑;No; ❑(Unknown;
i project (including all prior phases) in the ast ?S —
!Comments:
____ ____ _ _
4b. If the Corps made the jurisdictional determination, what type
of determination was made?
❑ Preliminary ❑ Final
4c. (If yes, who delineated the jurisdictional areas_ ?�
{Name (if known):; La U r� ((� k-[-(ae �
,,Agency/consultant c Jsulta_nt _Company: } -I
(Other:) � , U � � Q �e -,� (� (A-ir � 1
4d. , If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation)
5. Project History;+
(5a. Have permits or certifications been requested or obtam_ed for
"-
r - - -- -,
❑ Yes o� ❑Unknown
this project (including all rior phases) in the past?
fib. If yes,_explain in detail according to "help file" instructions_
6. Future Project Plans)
6a. Is this a phased proje
❑ Yes
6b. �If yes, explain
Page
�PCN Form - Version 1.4 January 2009

C. Proposed Impacts Inventory
1. Impacts Summary
1 a. Which sections were completed below for your project (check that apply):
❑ Wetlands ❑ Streams — tributaries Open Waters ❑ Pond Construction
2. Wetland Impacts
If there are wetland impacts proposed on the site, then complete this question for each wetland area impacted.
2a
Wetland impact
number
Permanent (P) or
Temporary
2b.
Type of impact
2c.
Type of wetland
2d.
Forested
2e.
Type of jurisdiction
Corps (404,10) or
DWQ (401, other)
2f.
Area of
impact
(acres)
W1 -
Choose one
Choose one
Yes/No
-
W2 -
Choose one
Choose one
Yes/No
-
W3 -
Choose one
Choose one
Yes/No
-
W4 -
Choose one
Choose one
Yes/No
-
W5 -
Choose one
Choose one
Yes/No
-
W6 -
Choose one
Choose one
Yes/No
-
2g. Total Wetland Impacts:
2h. Comments:
3. Stream Impacts
If there are perennial or intermittent stream impacts (including temporary impacts) proposed on the site, then complete this
question for all stream sites impacted.
3a.
Stream impact
number
Permanent (P) or
Temporary (T)
3b.
Type of impact
3c.
Stream name
3d.
Perennial (PER) or
intermittent (INT)?
3e.
Type of
jurisdiction
3f.
Average
stream
width
(feet)
3g.
Impact
length
(linear
feet)
S1 -
Choose one
-
S2 -
Choose one
-
-
S3 -
Choose one
S4 -
Choose one
-
-
S5 -
Choose one
-
S6 -
Choose one
-
3h Total stream and tributary impacts
3i. Comments:
Page 4 of 10
PCN Form — Version 1.4 January 2009

4. Open Water Impacts
If there are proposed impacts to lakes, ponds, estuaries, tributaries, sounds, the Atlantic Ocean, or any other open water of
the U.S. then indivi ually list all open water impacts below.
4a.
4b.
4c.
4d.
4e.
Open water
Name of waterbody
impact number
(if applicable)
Type of impact
Waterbody
Area of impact (acres)
Permanent (P) or
type
Temporary
01 -
Choose one
Choose
02 -
Choose one
Choose
03 -
Choose one
Choose
04 -
Choose one
Choose
4f. Total open water impacts
4g. Comments:
5. Pond or Lake Construction
If pond or lake construction proposed, the complete the chart below.
5a.
5b.
5c.
5d.
5e.
Pond ID number
Proposed use or
Wetland Impacts (acres)
Stream Impacts (feet)
Upland
purpose of pond
(acres)
Flooded
Filled
Excavated
Flooded
Filled
Excavated
P1
Choose one
P2
Choose one
5f. Total:
5g. Comments:
5h. Is a dam high hazard permit required?
❑ Yes ❑ No If yes, permit ID no:
5i. Expected pond surface area (acres):
5j. Size of pond watershed (acres):
5k Method of construction:
Buffer Impacts (for DWQ)1
If project will impact a protected riparian buffer, then complete the chart below. If yes, then individually list all buffer impacts
below If any impacts require mitigation. then you MUST fill out Section D of this form
`6a. Project is in which protected basin ?;
euse E] Tar-Pamlico E] Catawba ❑Randleman ❑Other:
6b.
6c.
6d.
6e.
6f.
6g.
Buffer Impactr
Reason for impacts
Stream name;'
rBuffer)_
_
Zone 1 i
;Zone 2�
_
number -'
- _ _. _ _ J
miti ation i
g
S
Iimpact,
,impact,
(Permanent (P) orb
required ?)
i� squar�
�ifeet
.:
i
,((square)
feet))
131
0 Lk S e
UT -�0 (At t7 e
Ye o
B2 -
Yes /No
B3 -
Yes/No
B4 -
Yes/No
B5 -
Yes/No
B6 -
Yes/Plo
6h. Total Buffer Impacts:
6i' Comments'.-
,;> Pk fk4 P f I r rl g -
24'reel Wee 76) 5 aw
Page 5 of 10 je (,tS`p� (l5-Sc IL
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D. Impact Justification and Mitigation
1. ;Avoidance and Minimization
1'a,. e-c-i fl- c a 1-1 y describe measures taken _to­ avoid _6r minimize the proposed impacts in designing projectji
- --- _ - - I a, 41 d
"'tr Qnfprv#"� df "/ 5 Ou 5 ' -Fry
L45 -z-ou e Z, 4;-,d O'e " eeA it/, re-, t4 fT Mtn( Zee D A C_ f S qLO
I b�' -S-'P-e-ci-fi-c-all-y--d-e-sc-r-i'-be me- a-sures taken to avoid or minimize the proposed impacts t rough construction techniques
0 ak4 4 V-4
2. Compensatory Mitigation for Impacts to Waters of the U.S. or Waters of the State
2a. Does the project require Compensatory Mitigation for
impacts to Waters of the U.S. or Waters of the State?
❑ Yes ❑ No
2b. If yes, mitigation is required by (check all that apply):
❑ DWQ ❑ Corps
2c. If yes, which mitigation option will be used for this
project?
❑ Mitigation bank
Payment to in-lieu fee program
❑ Permittee Responsible Mitigation
3. Complete if Using a Mitigation Bank
3a. Name of Mitigation Bank
3b Credits Purchased (attach receipt and letter)
Type: Choose one
Type: Choose one
Type: Choose one
Quantity:
Quantity:
Quantity.
3c Comments:
4. Complete if Making a Payment to In-lieu Fee Program
4a Approval letter from in-lieu fee program is attached.
❑ Yes
4b Stream mitigation requested:
linear feet
4c If using stream mitigation, stream temperature:
Choose one
4d. Buffer mitigation requested (DWQ only):
square feet
4e. Riparian wetland mitigation requested.
acres
4f. Non-riparian wetland mitigation requested:
acres
4g. Coastal (tidal) wetland mitigation requested:
-,acres
4h Comments:
6. Complete if Using a Permittee Responsible Mitigation Plan
5a. If using a permittee responsible mitigation plan, provide a description of the proposed mitigation plan.
Page 6 of 10
PCN Form - Version 1.4 January 2009
15
W /2

6. (,Buffer Mitigation -(State -Regulated -Riparian -Buffer —Rules) --re-q-u-i—red b_yD_WQ)
Will the project result in an impact within a.protected riparian buffer that
tl� _*q
E] Yes Iq 0
buffer tlo�
ltla�
6b. elf yes, then identify the square feet of impact to each zone of the riparian buffer that requires mitigation _Calculate the'
of
zone_
amount of mitigation r!�qorl�qj
for impacU
T)tal impact
Required mitigation
"f
�(§q.uare feet))
Zone 1
3 (2 for Catawba)
Zone 2
1.5
6f,( ion required:
6g. 1,,I(_ buffer m`it_ija_ iC6ii-7ii'-re-q-u-ir-ed-,-d-isc-u,s-s-w-h-a-t-t-y-p-e--o-f--mi-ti-g--a,-ti-o- -n--is---,p--r-o-p-os-e-d-(-e.-g-.-, payment to private mitigation q!j�r�, i
'permittee responsible riparian buffer restoration, payment into an approved in-lieu fee fund).; -
6h.
Page 7 of 10

E. Stormwater Management and Diffuse Flow Plan (required by DWQ)
1. (Diffuse Flow Plan)
(1a_ Does the project include or is it adjacent to protected riparian buffers identified)
A
❑
(within one of the NC Riparian Buffer Protection Rules?,,,
` - '� `
1 b. If yes, then is a diffuse flow plan included? If —no, explain wh J
`i t(� Q t�
u �'� W t ( G(� Uhf d u lQ
9
g-Ye's ❑ No
2. Stormwater Management Plan
2a. What is the overall percent imperviousness of this project?
2b. Does this project require a Stormwater Management Plan?
❑ Yes ❑ No
2c. If this project DOES NOT require a Stormwater Management Plan, explain why:
2d. If this project DOES require a Stormwater Management Plan, then provide a brief, narrative description of the plan.
2e. Who will be responsible for the review of the Stormwater Management Plan?
3. Certified Local Government Stormwater Review
3a. In which local government's jurisdiction is this project?
❑ Phase II
3b. Which of the following locally- implemented stormwater management programs
❑ NSW
apply (check all that apply):
❑ USMP
❑ Water Supply Watershed
❑ Other:
3c Has the approved Stormwater Management Plan with proof of approval been
El Yes ❑ No
attached?
4. DWQ Stormwater Program Review
❑Coastal counties
❑HQW
4a. Which of the following state - implemented stormwater management programs apply
❑ORW
(check all that apply):
❑Session Law 2006 -246
[]Other:
4b. Has the approved Stormwater Management Plan with proof of approval been
❑ Yes ❑ No
attached?
5. DWQ 401 Unit Stormwater Review
5a. Does the Stormwater Management Plan meet the appropriate requirements?
❑ Yes ❑ No
5b. Have all of the 401 Unit submittal requirements been met?
❑ Yes ❑ No
Page 8 of 10
PCN Form — Version 1.4 January 2009

F. Supplementary Information
1. Environmental Documentation (DWQ Requirement)
1 a. Does the project involve an expenditure of public (federal /state /local) funds or the
use of public (federal /state) land?
❑ Yes
❑ No
1 b. If you answered "yes" to the above, does the project require preparation of an
environmental document pursuant to the requirements of the National or State
(North Carolina) Environmental Policy Act (NEPA/SEPA)?
❑ Yes
❑ No
1 c. If you answered "yes" to the above, has the document review been finalized by the
State Clearing House? (If so, attach a copy of the NEPA or SEPA final approval
letter.)
Comments:
❑ Yes
❑ No
2. Violations (DWQ Requirement)
El Yes
���
MWOo
2a. s the site in violation of DWQ Wetland Rules (15A NCAC 2H .0500), Isolated)--
Wetland Rules (15A NCAC 2H .1300), DWQ Surface-Water or Wetland_ Standards,)
;or Riparian Buffer Rules-(1 5A NCAC 2B .0200)?) _
2b. (" this an after-the-fact permit application?)
❑Yes
�o
i2c. If you answered "yes" to one or both of the above questions Frov dde an explanation of the violation(s):
3. Cumulative Impacts (DWQ Requirement)
3a tld ll this project (based on past and reasonably anticipated future impacts) result �nj
it ional development, which could impact nearby downstream water quality?)^- -
El Yes
L<O
3b If you answered "yes" to the above, submit a qualitative or quantitative cumulative impact analysis in accordance with the
most recent qWq policy. If you answered "no," provide a short narrative description.l
4. Sewage Disposal (DWQ Requirement)
4a. Clearly detail the ultimate treatment methods and disposition (non- discharge or discharge) of wastewater generated from
the proposed project, or available capacity of the subject facility.
Page 9 of 10
PCN Form — Version 1.4 January 2009

S. Endangered Species and Designated Critical Habitat (Corps Requirement)
5a. Will this project occur in or near an area with federally protected species or
habitat?
El Yes No
❑
5b. Have you checked with the USFWS concerning Endangered Species Act
impacts?
❑ Yes ❑ No
5c. If yes, Indicate the USFWS Field Office you have contacted.
-
5d. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical
Habitat?
6. Essential Fish Habitat (Corps Requirement)
6a Will this project occur in or near an area designated as essential fish habitat?
❑ Yes ❑ No
6b. What data sources did you use to determine whether your site would impact Essential Fish Habitat?
7. Historic or Prehistoric Cultural Resources (Corps Requirement)
7a. Will this project occur in or near an area that the state, federal or tribal
governments have designated as having historic or cultural preservation
status (e.g., National Historic Trust designation or properties significant in
North Carolina history and archaeology)?
❑ Yes ❑ No
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?
8. Flood Zone Designation (Corps Requirement)
8a. Will this project occur in a FEMA- designated 100 -year floodplain?
❑ Yes ❑ No
8b. If yes, explain how project meets FEMA requirements -
8c. What source(s) did you use to make the floodplain determination?
l--d A Y���B r�'
CA Pli_ a nA eni ts V — —me
t 3� zAi
tef
t(ApplicantA a nt's S naturPr e
Agent's signature is lid only if an authonzation
letter from the applicant is provided.))
Page 10 of 10